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Definition

Female Genital Mutilation (FGM) comprises all procedures that involve the partial or total removal of external genitalia, or other injury to the female genital organs for non-medical reasons. It is a very traumatic and violent act for the victim and can cause harm in many ways. The practice can cause severe pain and there may be immediate and long-term health consequences, including physical problems, mental health problems, and complications in childbirth. Girls and women who have undergone FGM are at risk of suffering from its complications throughout their lives.

The age at which FGM is carried out varies enormously according to the community. The procedure may be carried out shortly after birth, during childhood or adolescence, just before marriage or during a woman’s first pregnancy.

FGM is a criminal offence; it is child abuse and a form of violence against women and girls, and should, therefore, be treated as such. Cases should be dealt with as part of existing Child Protection and Safeguarding Adults policies and procedures. There are, however particular characteristics of FGM that front line professionals should be aware of to ensure that they can provide appropriate protection and support to those affected.

FGM is a deeply rooted practice, widely carried out mainly among specific ethnic populations in Africa and parts of the Middle East and Asia. It serves as a complex form of social control of women’s sexual and reproductive rights.

For more detail, please refer to the Multi Agency Statutory Guidance on Female Genital Mutilation April 2016 

Click here to access the GOV.UK website for Female Genital Mutilation: help and advice.

Opposing Statement

Female Genital Mutilation (FGM) is an extremely harmful practice with devastating health consequences for girls and women. Some girls die from blood loss or infection as a direct result of the procedure. Women who have undergone FGM are also likely to experience difficulty in childbirth and many also suffer from long-term psychological trauma.

There is no Biblical or Koranic justification for FGM and religious leaders from all faiths have spoken out against the practice.

Justifications given for FGM

The justifications given for the practise are multiple and reflect the ideological and historical situation of the societies in which it has developed. Reasons include:

  1. Custom and tradition;
  2. Religion, in the mistaken belief that it is a religious requirement;
  3. Preservation of virginity/chastity;
  4. Social acceptance, especially for marriage;
  5. Hygiene and cleanliness;
  6. Increasing sexual pleasure for the male;
  7. Family honour;
  8. A sense of belonging to the group and conversely the fear of social exclusion;
  9. Enhancing fertility.

Consequences of FGM

Depending on the degree of mutilation, FGM can have a number of short-term health implications:

  1. Severe pain and shock;
  2. Infection;
  3. Urine retention;
  4. Injury to adjacent tissues;
  5. Immediate fatal haemorrhaging;
  6. Death.

Long-term implications can entail:

  1. Extensive damage of the external reproductive system;
  2. Uterus, vaginal and pelvic infections;
  3. Cysts and neuromas;
  4. Increased risk of Vesico Vaginal Fistula;
  5. Complications in pregnancy and child birth;
  6. Psychological damage;
  7. Pain during sexual intercourse;
  8. Sexual dysfunction;
  9. Difficulties in menstruation and urination;
  10. Urine infections.

In addition to these health consequences there are considerable psycho-sexual, psychological and social consequences of FGM. Internationally 10% of child victims of Type 3 FGM die.


Prevalence of FGM

Globally - The exact number of girls and women alive today who have undergone FGM is unknown. UNICEF estimates that over 200 million girls and women worldwide have undergone FGM

While FGM is concentrated in countries around the Atlantic coast to the Horn of Africa, and areas of the Middle East like Iraq and Yemen, it has been documented in communities in:

Colombia
Iran
Israel
Oman
The United Arab Emirates
The Occupied Palestinian Territories
India
Indonesia
Malaysia
Pakistan
Saudi Arabia

It has also been identified in parts of Europe, North America and Australia.

In England and Wales - The prevalence of FGM in England and Wales is difficult to estimate because of the hidden nature of the crime. However, a 2015 study estimated that:

  • Approximately 60,000 girls aged 0-14 were born in England and Wales to mothers who had undergone FGM (see Annex B: of Multi Agency Statutory Guidance on Female Genital Mutilation (HM Government, 2016) for risk factors; and
  • Approximately 103,000 women aged 15-49 and approximately 24,000 women aged 50 and over who have migrated to England and Wales are living with the consequences of FGM. In addition, approximately 10,000 girls aged under 15 who have migrated to England and Wales are likely to have undergone FGM.

 


Identifying and responding to FGM

The following principles should be adopted by all agencies in relation to identifying and responding to those at risk of, or who have undergone FGM, and their parent(s) or guardians:

  • The safety and welfare of the child is paramount;
  • All agencies should act in the interests of the rights of the child, as stated in the United Nations Convention on the Rights of the Child (1989);
  • FGM is illegal in the UK (see The Law below);
  • FGM is an extremely harmful practice - responding to it cannot be left to personal choice;
  • Accessible, high quality and sensitive health, education, Police, Social Care and voluntary sector services must underpin all interventions;
  • FGM is an embedded social cultural practice therefore engagement with families and communities plays an important role in contributing to ending this practice;
  • All decisions or plans should be based on high quality assessments in accordance with Working Together to Safeguard Children (2015).

Identifying concerns

FGM is known by a variety of names, including ‘female genital cutting’, ‘circumcision’ or ‘initiation’. The term ‘female circumcision’ is anatomically incorrect and misleading in terms of the harm FGM can cause. The terms ‘FGM’ or ‘cut’ are increasingly used at a community level, although they are not always understood by individuals in practising communities, largely because they are English terms.

No single professional can have a full picture of an individual’s needs and circumstances. To ensure that women and girls affected by FGM receive the right help at the right time, everyone who comes into contact with them has a role to play.


Risk Factors

The most significant factor to consider when deciding whether a girl or woman may be at risk of FGM is whether her family has a history of practising FGM. In addition, it is important to consider whether FGM is known to be practised in her community or country of origin and whether there is a positive attitude towards FGM within that culture.

The age at which girls undergo FGM varies enormously according to the community. The procedure may be carried out when the girl is new-born, during childhood or adolescence, at marriage or during a first pregnancy.

Given the hidden nature of FGM, individuals from communities where it takes place may not be aware of the practice. Women and girls who have undergone FGM may not fully understand what FGM is, what the consequences are, or that they themselves have had FGM. Given this context, discussions about FGM should always be undertaken with appropriate care and sensitivity.

It is believed that FGM may happen to girls in the UK as well as overseas. Girls of school age who are subjected to FGM overseas are likely to be taken abroad (often to the family’s country of origin) at the start of the school holidays, particularly in the summer, in order for there to be sufficient time for her to recover before returning to school.

There are a number of factors in addition to a girl’s or woman’s community, country of origin and family history that could indicate she is at risk of being subjected to FGM. Potential risk factors may include:

  • A female child is born to a woman who has undergone FGM;
  • A female child has an older sibling or cousin who has undergone FGM;
  • A female child’s father comes from a community known to practice FGM;
  • The family indicate that there are strong levels of influence held by elders and/or elders are involved in bringing up female children;
  • A woman/family believe FGM is integral to cultural or religious identity;
  • A girl/family has limited level of integration within UK community;
  • Parents have limited access to information about FGM and do not know about the harmful effects of FGM or UK law;
  • A girl confides to a professional that she is to have a ‘special procedure’ or to attend a special occasion to ‘become a woman’;
  • A girl talks about a long holiday to her country of origin or another country where the practice is prevalent;
  • Parents state that they or a relative will take the girl out of the country for a prolonged period;
  • A parent or family member expresses concern that FGM may be carried out on the girl;
  • A family is not engaging with professionals (health, education or other);
  • A family is already known to social care in relation to other safeguarding issues;
  • A girl requests help from a teacher or another adult because she is aware or suspects that she is at immediate risk of FGM;
  • A girl talks about FGM in conversation, for example, a girl may tell other children about it – it is important to take into account the context of the discussion;
  • A girl from a practising community is withdrawn from Personal, Social, Health and Economic (PSHE) education or its equivalent;
  • A girl is unexpectedly absent from school;
  • Sections are missing from a girl’s Red book; and/or
  • A girl has attended a travel clinic or equivalent for vaccinations / anti-malarials.

Remember: This is not an exhaustive list of risk factors. There may be additional risk factors specific to particular communities. For example, in certain communities FGM is closely associated to when a girl reaches a particular age.

If any of these risk factors are identified professionals will need to consider what action to take. If unsure whether the level of risk requires referral at this point, professionals should discuss with their named/designated safeguarding lead.

If the risk of harm is imminent, emergency measures may be required.

If you are worried about a girl under 18 who is either at risk of FGM or who you suspect may have had FGM, you should share this information with Children’s social care or the police immediately (See Any Contacts with Children’s Social Care (including Information Sharing and Referrals)).

See also Annex B: of Multi Agency Statutory Guidance on Female Genital Mutilation (GOV.UK, 2016) for details.

Contact with parents / family

Professionals must take into consideration that by alerting the girl’s or woman’s family to the fact that she is disclosing information about FGM may place her at increased risk of harm, and professionals should therefore take appropriate steps to minimise this risk.

It should not be assumed that families from practicing communities will want girls and women to undergo FGM.

For more information on consent please see the Effective Communication, Consent and Information Sharing Procedure.

Indicators that FGM May Have Already Taken Place

It is important that professionals look out for signs that FGM has already taken place so that:

  • The girl or woman receives the care and support she needs to deal with its effects;
  • Enquiries can be made about other female family members who may need to be safeguarded from harm; and/or
  • Criminal investigations into the perpetrators, including those who carry out the procedure, can be considered to prosecute those who have broken the law and to protect others from harm.

There are a number of indications that a girl or woman has already been subjected to FGM:

  • A girl or woman asks for help;
  • A girl or woman confides in a professional that FGM has taken place;
  • A mother/family member discloses that female child has had FGM;
  • A family/child is already known to social services in relation to other safeguarding issues;
  • A girl or woman has difficulty walking, sitting or standing or looks uncomfortable;
  • A girl or woman finds it hard to sit still for long periods of time, and this was not a problem previously;
  • A girl or woman spends longer than normal in the bathroom or toilet due to difficulties urinating;
  • A girl spends long periods of time away from a classroom during the day with bladder or menstrual problems;
  • A girl or woman has frequent urinary, menstrual or stomach problems;
  • A girl avoids physical exercise or requires to be excused from physical education (PE) lessons without a GP’s letter;
  • There are prolonged or repeated absences from school or college (see Children Missing Education—Statutory Guidance for Local Authorities, 2016);
  • Increased emotional and psychological needs, for example withdrawal or depression, or significant change in behaviour;
  • A girl or woman is reluctant to undergo any medical examinations;
  • A girl or woman asks for help, but is not be explicit about the problem; and/or
  • A girl talks about pain or discomfort between her legs.

This is not an exhaustive list of indicators. If any of these indicators are identified professionals will need to consider what action to take. If unsure what action to take, professionals should discuss with their named/designated safeguarding lead.


Protection and Action to be Taken

Where concerns about the welfare and safety of a child or young person have come to light in relation to FGM a referral to Children’s Social Care should be made in accordance with the Any Contacts with Children's Social Care (including Information Sharing and Referrals) Procedure.

Where it has been established that the child is suffering or likely to suffer Significant Harm, Children’s Social Care will undertake an assessment and, jointly with the Police, will undertake a Section 47 Enquiry if they have reason to believe that a child is likely to suffer or has suffered FGM. A Strategy Discussion/Meeting should include the relevant Health professionals and, if the child is of school age, the relevant school representative.

In line with local procedures, Strategy Meetings should be held as soon as practicable bearing in mind the needs of the child. Consideration should be given to the meeting being chaired by a member of the Independent Conference and Review Team. It should also include local specialist practitioners where appropriate.

The appropriateness of decisions that are agreed at a Strategy Meeting should be subject to regular review, bearing in mind the safety of the child at all times.

Where a child has been identified as having suffered, or being likely to suffer, significant harm, it may not always be appropriate to remove the child from an otherwise loving family environment. Parents and carers may genuinely believe that it is in the girl’s best interest to conform to their prevailing custom.

Professionals should work in a sensitive manner with families to explain the legal position around FGM in the UK. The families will need to understand that FGM and re-infibulation (the procedure to narrow the vaginal opening in a woman after she has been deinfibulated (i.e. after childbirth); also known as re-suturing) is illegal in the UK and that if they are insistent upon carrying out the practice, Children’s Social Care and other health professional involved in the care of the child and family, must be informed that a female child is likely to suffer significant harm.

Where a child appears to be in immediate danger of FGM, legal advice should be sought and consideration should be given, for example, seeking a Female Genital Mutilation Protection Order, an Emergency Protection Order or a Prohibited Steps Order, making it clear to the family that they will be breaking the law if they arrange for the child to have the procedure.

The 2003 Female Genital Mutilation Act makes it illegal for any residents of the UK to perform FGM within or outside the UK. The punishment for violating the 2003 Act carries 14 years imprisonment, a fine or both.

It is also an offence to take a child out of the country in order to carry out FGM.

FGM Protection Orders (FGMPO)

An FGMPO is a civil order which may be made for the purposes of protecting a girl30 against the commission of an FGM offence – that is, protecting a girl at risk of FGM - or protecting a girl against whom an FGM offence has been committed. In deciding whether to make an order a court must have regard to all the circumstances of a case including the need to secure the health, safety and well-being of the potential or actual victim. The court can make an order which prohibits, requires, restricts or includes any other such other terms as it considers appropriate to stop or change the behaviour or conduct of those who would seek to subject a girl to FGM or have already arranged for, or committed, FGM.

Medical assessments

Where it is suspected that FGM may have been carried out on a child or young person then a medical assessment may be considered as part of a Child Protection Enquiries - Section 47 Children Act 1989. Medical assessments should always be considered where there has been a disclosure or there is a suspicion of any form of abuse.

Medical assessments can be requested by Local Authority Children’s Social Care or the Police by contacting Hull and East Yorkshire Hospital Trust, Anlaby suite, who will arrange for the most appropriate medical practitioner to complete the assessment on 01482 675935.

A medical assessment should demonstrate a holistic approach to the child and assess the child’s wellbeing, including mental health, development and cognitive ability.

It is always best practice for medicals in relation to FGM to be carried out jointly by a paediatrician and a doctor specialist in FGM. Only doctors may physically examine the whole child.

The General Medical Council has issued guidance on child protection examinations. This guidance covers the considerations around obtaining consent (required), and what to do if it is not given.

Interpreters

FGM is a complex and sensitive issue that requires professionals to approach the subject carefully. An accredited female interpreter may be required. Any interpreter should ideally be appropriately trained in relation to FGM, and in all cases should not be a family member, not be known to the individual, and not be someone with influence in the individual’s community.

Interpretation services should be used if English is not spoken or well understood and the interpreter (preferably female) should not be an individual who is known to the family. Always discuss with the interpreter prior to consultation as she may need issues explaining, or she may have had FGM herself and may find it difficult to discuss. The interpreter should not be someone within the same community as they may have individual influence within that community. See also Working with Interpreters Safeguarding Practice Guidance.

Psychological support

Women and girls who have had FGM can have a variety of different needs for care and support, and may seek help from a range of places. FGM can be an extremely traumatic experience which stays with them for the rest of their lives. There is an increasing awareness of the severe psychological consequences of FGM which can become evident in mental health problems. Where a woman or girl has undergone FGM a referral for psychological support should be offered through The Single Point of Access service on 01482 336161.


Links to Forced marriage and Honour Based Abuse

FGM is a form of violence against women and girls which is, in itself, both a cause and consequence of gender inequality. Whilst FGM may be an isolated incident of abuse within a family, it can be associated with other behaviours that discriminate against, limit or harm women and girls. These may include other forms of Honour-Based Abuse (e.g. forced marriage) and domestic abuse.

There have been reports of cases where individuals have been subjected to both FGM and forced marriage. If a professional has a concern about an individual who may be at risk of forced marriage, please see the Forced Marriage Practice Guidance.


Health Agency Additional Actions

The FGM Enhanced Dataset Information Standard also instructs NHS acute and mental health trusts and GP practices on how they should submit data about patients who have FGM to the Health and Social Care Information Centre (HSCIC). HSCIC collect and publish anonymised statistics on behalf of the Department of Health and NHS England. The information is used nationally and locally to improve the NHS response to FGM and to help commission the services to support women who have experienced FGM and safeguard women and girls at risk of FGM.

It is important to note that the personal information held and collected under the FGM Enhanced Dataset Information Standard is not released to anyone outside of HSCIC. If these arrangements were to change, any information which was held prior to such a change would continue to be protected under the current arrangements.

Guidance on the recording of FGM and the FGM Enhanced dataset standard is available at: www.hscic.gov.uk/fgm.


Mandatory Reporting of FGM

Since 31st October 2015, regulated health and social care professionals and teachers in England and Wales have a duty to report to the police ‘known’ cases of FGM in under 18s which they identify in the course of their professional work.

Mandatory reporting does not replace existing safeguarding procedures for children or adults with care or support needs but is an additional responsibility for named professionals.

Professionals covered by this duty include:

  • General Chiropractic Council;
  • General Dental Council;
  • General Medical Council;
  • General Optical Council;
  • General Osteopathic Council;
  • General Pharmaceutical Council;
  • Health and Care Professions Council (whose role includes the regulation of social workers in England);
  • Nursing and Midwifery Council;
  • Teachers - this includes qualified teachers or persons who are employed or engaged to carry out teaching work in schools and other institutions.

While the duty is limited to the specified professionals described above, non-regulated practitioners still have a general responsibility to report cases of FGM, in line with wider safeguarding frameworks. If a non-regulated professional becomes aware that FGM has been carried out on a girl under 18, they should still share this information within their local safeguarding lead, and follow their organisation’s safeguarding procedures.

‘Known’ cases are those where regulated health and social care professionals and teachers in England and Wales, in the course of their professional duties, either:

  • Are informed by a girl under 18 that an act of FGM has been carried out on her; or
  • Observe physical signs which appear to show that an act of FGM has been carried out on a girl under 18 and they have no reason to believe that the act was necessary for the girl’s physical or mental health or for purposes connected with labour or birth.

A failure to report the discovery in the course of their work could result in a referral to their professional body.

Where it becomes ‘known’ to a professional that a child under 18 years has undergone FGM then they must report it through the Police 101 non emergency number, they will be asked a series of information gathering questions and then be given a log number which they must record in line with their agency recording policy.

Reports under the duty should be made as soon as possible after a case is discovered, and best practice is for reports to be made by the close of the next working day. In order to allow for exceptional cases, a maximum timeframe of one month from when the discovery is made applies for making reports. However, the expectation is that reports will be made much sooner than this.

For information about the questions you will be asked when phoning 101 please see the Humberside Police FGM Mandatory Reporting Form.

Professionals covered under this duty do not need to gain consent in order to make contact. However to consider consent would always be best practice.

Professionals will be given a log number by Police staff which they must record in line with their own agencies recording processes.

FGM Mandatory Reporting Duty: Additional Resources

Information for professionals subject the duty and their employers, including on how to make a report please see:

Mandatory Reporting of FGM – Procedural Information (HM Government).

Additional information for health care professionals in England is available at: FGM Mandatory Reporting in Healthcare (HM Government).


The Law

In England and Wales, criminal and civil legislation on FGM is contained in the Female Genital Mutilation Act 2003 (‘the 2003 Act’). The act:

  • Makes it illegal to practice FGM in the UK;
  • Makes it illegal to take girls who are British nationals or permanent residents of the UK abroad for FGM whether or not it is lawful in that country;
  • Makes it illegal to aid, abet, counsel or procure the carrying out of FGM abroad;
  • Has a penalty of up to 14 years in prison and, or, a fine.

As amended by the Serious Crime Act 2015, the Female Genital Mutilation Act 2003 now includes:

Creating a new offence of failing to protect a girl from FGM with a penalty of up to 7 years in prison or a fine or both. - A person is liable if they are “responsible” for a girl at the time when an offence is committed. This will cover someone who has “parental responsibility” for the girl and has “frequent contact” with her and any adult who has assumed responsibility for caring for the girl in the manner of a parent. This could be for example family members, with whom she was staying during the school holidays;

Introduced Female Genital Mutilation Protection Orders (“FGMPO”) - breaching an order carries a penalty of up to five years in prison. The terms of the order can be flexible and the court can include whatever terms it considers necessary and appropriate to protect the girl or woman;

Allowing for the lifelong anonymity of victims of FGM – prohibiting the publication of any information that could lead to the identification of the victim. Publication covers all aspects of media including social media;

Extending the extra-territorial reach of Female Genital Mutilation (FGM) offences to include “habitual residents” of the UK;

Creating a new duty of Mandatory Reporting of Female Genital Mutilation for regulated professionals in health and social care professionals and teachers in England and Wales which came into force on the 31st October 2015.


Hull and East Yorkshire Hospital Trust position on Labial Surgery

Hull and East Yorkshire Hospitals NHS Trust does not support labial reduction surgery (labiaplasty, labial trimming, female genital cosmetic surgery (FGCS)) in girls under 18 years, the only exception being if the case has been heard before the exception treatments panel.

There is no recognisable disease process warranting surgical treatment and no creditable evidence to demonstrate lasting effectiveness along physical, psychological and sexual parameters. Labial growth and development is part of pubertal development and may not be completed until early adulthood. There are known and probable risks to surgical alterations of healthy morphological development. In the absence of an identifiable disease, and until the evidence demonstrates to the contrary, labiaplasty should not be performed on girls under the age of 18 years. There is no scientific evidence to support the practice of labiaplasty and, for girls under the age of 18 years; the risk of harm is even more significant (Royal College of Obstetricians and Gynaecologists 2015).


Further Information

Training

The Home Office have produced a useful online training resource covering the basics of FGM

http://www.fgmelearning.co.uk/

Hull Safeguarding Children Board run an awareness course covering Forced Marriage, Honour Based Abuse and Female Genital Mutilation

Pre-requisites for attending this course include safeguarding level 1 and becoming culturally competent

learninganddevelopment@hullcc.gov.uk
Tel: 01482 612442

Further Information

AFRUCA (Child Protection of African Children) 

Forward (Foundation for Women's Health Research and Development)

FGM Protection Orders: Factsheet

Female Genital Mutilation and its Management: Royal College of Obstetricians and Gynaecologists 2015

Female Genital Mutilation: Resource Pack

Mandatory Reporting of Female Genital Mutilation – procedural information

For further information please see Multi Agency Statutory Guidance on Female Genital Mutilation (HM Government, 2016).

Female Genital Mutilation Risk and Safeguarding – Guidance for Professionals (DoH)

Statement opposing Female Genital Mutilation (Health passport)

Safeguarding Women and Girls at Risk of FGM (DoH)


Amendments to this Chapter

In January 2018, a new section was added to this procedure outlining the Hull and East Yorkshire Hospital Trust position on Labial Surgery. In summary, the Trust does not support labial reduction surgery (labiaplasty, labial trimming, female genital cosmetic surgery (FGCS)) in girls under 18 years.

End.